When Liz Tidyman鈥檚 elderly parents moved across the country to be closer to their children and grandchildren years ago, they carried their medical records with them in a couple of brown cardboard folders tied with string.
Two days after their arrival, Tidyman鈥檚 father fell, which hadn鈥檛 happened before, and went to a hospital for an evaluation.
In the waiting room, Tidyman opened the folder. 鈥淰ery soon I saw that there were pages and pages of notes that referred to a different person with the same name 鈥� a person whose medical conditions were much more complicated and numerous than my father鈥檚,鈥� she said.
Tidyman pulled out sheets with mistaken information and made a mental note to always check records in the future. 鈥淭hat was a wake-up call,鈥� she said.
Older adults have cause to be careful about what鈥檚 in their medical records. Although definitive data aren鈥檛 available, the estimates that nearly 1 in 10 people who access records online end up requesting that they be corrected for a variety of reasons.
In the worst-case scenario, an incorrect diagnosis, scan or lab result may have been inserted into a record, raising the possibility of inappropriate medical evaluation or treatment. This, too, is something that Tidyman鈥檚 father encountered soon after moving from Massachusetts to Washington. (Her parents have since passed away.)
When both his new primary care physician and cardiologist asked about kidney cancer 鈥� a condition he didn鈥檛 have 鈥� Tidyman reviewed materials from her father鈥檚 emergency room visit. There, she saw that 鈥渞enal cell carcinoma鈥� (kidney cancer) was listed instead of 鈥渂asal cell carcinoma鈥� (skin cancer) 鈥� an illness her father had mentioned while describing his medical history.
鈥淚t was a transcription error; something we clearly had to fix,鈥� Tidyman said.
Omissions from medical records 鈥� allergies that aren鈥檛 noted, lab results that aren鈥檛 recorded, medications that aren鈥檛 listed 鈥� can be equally devastating.
Susan Sheridan discovered this nearly 20 years ago after her husband, Pat, had surgery to remove a mass in his neck. A hospital pathology report identified synovial cell sarcoma, a type of cancer, but somehow the report didn鈥檛 reach his neurosurgeon. Instead, the surgeon reassured the couple that the tumor was benign.
Six months later, when Pat returned to the hospital in distress, this error of omission was discovered. By then, Pat鈥檚 untreated cancer had metastasized to his spinal canal. He died 2陆 years later.
鈥淚 tell people, 鈥楥ollect all your medical records, no matter what鈥� so you can ask all kinds of questions and be on the alert for errors,鈥� said Sheridan, director of patient engagement with the Society to Improve Diagnosis in Medicine.
In less dire scenarios, a patient鈥檚 name, address, phone number or personal contacts may be incorrect, making it difficult to reach someone in the event of an emergency or causing a bill to be sent to the wrong location. Or, your family history may not be conveyed accurately. Or, you may not have received a service recorded in your record 鈥� for instance, a stress test 鈥� and want to contest the bill.
Dave deBronkart, a 68-year-old cancer survivor and patient activist, recounts mistakes he and his family have experienced. Once, he checked a radiology report through a Boston hospital鈥檚 patient portal. It had his name on it but identified him as a 53-year-old woman.
In another instance, the records that accompanied deBronkart鈥檚 mother to a rehabilitation center after a hip replacement incorrectly identified her as having an underactive thyroid when in fact she had an overactive thyroid. DeBronkart鈥檚 sisters, who asked to look at their mother鈥檚 chart, discovered the mistake and had it fixed on the spot, so she wouldn鈥檛 get potentially harmful medications.
鈥淚t鈥檚 important for people to realize how easy it is for mistakes to get into the system and for nobody to know it. And that can cause downstream harm,鈥� deBronkart said.
The law that guarantees your right to review your medical record, , offers some recourse: If you think you鈥檝e discovered an error in your medical record, you have the right to ask for a correction. (For more information about how to obtain your record, see my earlier column here.)
Start by asking your doctor or hospital if they have a form (either a paper or electronic version) you should use to submit a suggested change.
A simple error such as a wrong phone number can be corrected by drawing a thin line through the material and writing a suggested change in the margins or making an electronic note. A more complicated error such as incorrect description of your symptoms or a diagnosis that you鈥檙e contesting may require a brief statement from you explaining what material in the record is wrong, why and how it should be altered.
Physicians and hospitals are required to respond in writing within 60 days, with the possibility of a 30-day extension. (Some states set shorter deadlines.) But medical providers are not obligated to accept your request. If you receive a rejection, you have the right to add another statement contesting this decision to your medical record. You can also file a complaint with the or a state agency that licenses physicians.
Devin O鈥橞rien, senior counsel with The Doctors Company, the largest physician-owned medical malpractice firm in the U.S., notes that rejections can be warranted when facts or medical judgments are in question. An example might be a patient who wants a doctor鈥檚 notes about potentially excessive opioid use eliminated from the record. 鈥淭he patient may say I don鈥檛 have a problem, I don鈥檛 know what you鈥檙e talking about, but the physician may think the patient has an issue,鈥� O鈥橞rien said.
Another example might be a patient who wants a diagnosis eliminated from a medical record, because it might compromise her ability to get insurance coverage. That wouldn鈥檛 be an acceptable reason for making a change, experts said.
For more information about correcting errors in medical records, see from the Office of the National Coordinator for Health Information Technology, this from patient advocate Trisha Torrey, and these descriptions of your HIPAA rights from the and the .
We鈥檙e eager to hear from readers about questions you鈥檇 like answered, problems you鈥檝e been having with your care and advice you need in dealing with the health care system. Visit to submit your requests or tips.
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